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NSAIDs and opioids 63
For now, with a few possible exceptions such as arthritis pain (see p. 00),
we recommend ED providers avoid use of the COX-2 selective NSAIDs. This
general recommendation is subject to modification in particular clinical
circumstances, as outlined in other chapters of this text. Further data
will undoubtedly clarify the role of COX-2 selective NSAIDs for acute (and
chronic) analgesia.
If the side effects of the COX-2 selective NSAIDs require further elucidation,
there is much less uncertainty about risks associated with nonselective
NSAIDs. Among the issues to consider are GI bleeding, renal insufficiency,
and impaired fracture healing. These complications, which are less likely
with a few days’ use than with longer NSAID prescription, should inform – but
not dominate – emergency physicians’ drug decision-making. 10 Despite the
well-characterized NSAID risks, this class is still often the best choice for ED
patients. One reason is that the usual alternatives include agents with known
adverse effects of their own (e.g. opioids), or drugs with lesser analgesic
efficacy (e.g. acetaminophen).
The gastrointestinal risks of NSAIDs are reduced by co-administration of
gastroprotective therapy such as misoprostol or, preferably, proton pump
inhibitors. 11,12 Commentators supporting the use of proton pump inhibitors
in patients receiving NSAIDs cite data showing that, compared with NSAID
monotherapy, the dual-therapy approach reduces GI bleed incidence by
over 80%. 13 Pharmaco-economic analysis suggests that, for short-course
therapy prescribed from the ED, the combination will usually be more cost
effective than COX-2 selective NSAID monotherapy. 14
Perhaps surprisingly for many conditions described in this text, the combination
of NSAIDs and opioids fails to accrue additive (or synergistic) analgesic
results. The point is illustrated by recent data from a study of children with
suspected fractures. The authors of the study found that children with mild-tomoderate
pain responded equally well to ibuprofen (10 mg/kg PO), oxycodone
(0.1 mg/kg PO), or the combination of the two, and preferred monotherapy for
reasons of safety and simplicity. 15 The message for the ED physician is that
single-drug therapy may be best. Do not assume that NSAID-associated risks –
however small in an individual patient – are outweighed by analgesic benefit in
a patient who is already going to be taking opioids.